All Reports

Comprehensive Healthcare Inspection Program and Care in the Community Report: Mammography Services and Breast Cancer Care
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23-00540-146
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Topics:  Appointment Scheduling and Wait Times ● Care Coordination ● Community Care ● Women’s Health

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with the National Oncology Program and Veterans Integrated Service Network directors, ensure facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.

Increased Utilization of Primary Care in the Community by the VA Loma Linda Healthcare System in California
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23-01602-147
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Topics:  Appointment Scheduling and Wait Times ● Care Coordination ● Community Care ● Staffing

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director confirms that a mechanism is in place to monitor primary care patient aligned care team staffing and panel sizes at the non-VHA-operated clinics to ensure staff are available to care for enrolled patients.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director directs a review be done of VA Loma Linda Healthcare System adherence to Veterans Health Administration metrics for the processing and scheduling of community care consults and, if not met, determines the reasons for noncompliance, creates an action plan to address deficiencies, and monitors for compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director conducts an assessment of the community- based outpatient clinic steering committee to ensure consistent oversight of quality of care and staffing levels for all of the VA Loma Linda Healthcare System’s VA outpatient clinics.

Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma
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23-01325-59
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Topics:  Appointment Scheduling and Wait Times ● Mental Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, and takes action as warranted.

Care in the Community Summary Report for Fiscal Year 2022
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22-03772-28
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Topics:  Appointment Scheduling and Wait Times ● Care Coordination ● Community Care ● Mental Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.

VA Developed Reporting Metrics for Appeals Modernization Act Decision Reviews but Could Be Clearer on Some Veterans’ Wait Times
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22-00488-81
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Topics:  Claims and Appeals ● Appointment Scheduling and Wait Times

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No. 1
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Update the reporting methodology used in public reports to reflect the total time veterans wait for a final claims decision when their higher level reviews require a supplemental claim be established and completed due to an error.
No. 2
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Revise and clearly state the measures used for calculating and reporting the average duration, from the filing of an initial claim until the claim is resolved and claimants no longer take any action under the Appeals Modernization Act claim, and ensure consistency with subsection M of the act.
Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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21-02326-233
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Topics:  Community Care ● Care Coordination ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
New Patient Scheduling System Needs Improvement as VA Expands Its Implementation
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21-00434-233
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

Continue to make improvements to the scheduling training as needed to address feedback from schedulers.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

Provide guidance to schedulers to consistently address system limitations until problems are resolved.

Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina
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21-01304-275
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Topics:  COVID-19 ● Patient Safety ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care
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20-01141-145
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Communication of Test Results and Oncology Scheduling Concerns at the Beckley VA Medical Center in West Virginia
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20-00339-69
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Beckley VA Medical Center Director ensures that primary care providers comply with communicating laboratory test results to patients and documenting the discussion in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Beckley VA Medical Center Director ensures that the oncologist complies with facility scheduling and ordering policies including the Primary Care and Oncology Service Agreement.
Management and Oversight of the Electronic Wait List for Healthcare Services
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19-09161-02
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health has oversight controls developed and implemented to monitor all facilities’ patient care requests that are identified as “unable to schedule” to ensure patients across the Veterans Health Administration are scheduled in a timely manner.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures standard operating procedures are being implemented so that facility employees routinely review and act on patient care requests identified as “unable to schedule” in the consult toolbox.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health makes certain that facility leaders clearly define and oversee procedures on routinely reviewing, monitoring, and addressing transfer entries on the Light Electronic Administrative Framework.
Improved Oversight of Surgical Support Elements Would Enhance Operating Room Efficiency and Care
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18-06039-229
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Topics:  Clinical Care Services Operations ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 30,000,000.00
Consult Delays at the Atlanta VA Health Care System in Decatur, Georgia
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18-01622-207
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Topics:  Appointment Scheduling and Wait Times ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director reviews the process for non-VA community care consult performance measurements, evaluates compliance with Veterans Health Administration policy, and implements an action plan as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director ensures managers review the backlog of open non-VA community care consults and implements an action plan as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director verifies that managers develop a process to analyze and confirm non-VA community care staff compliance with daily monitoring according to Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director evaluates the process for the hiring, training, and supervision of non-VA community care staff, and implements an action plan as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director ensures that managers review the patient cases referred to the Atlanta VA Health Care System by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Atlanta VA Health Care System Director makes certain that managers develop a policy to identify non-VA Community Care consults that are administratively closed but do not have relevant medical documentation, and implements an action plan as needed to be in alignment with Veterans Health Administration policy.
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